Findings:
Both articles reviewed for this quarter’s neuropsychiatry annotations appear in the winter issue of the Journal of Neuropsychiatry and Clinical Neurosciences, which focuses entirely on functional neurologic disorders (FND).The findings of this article, collected retrospectively from three FND specialist clinics across three countries, are hardly surprising, but offer additional data to support the need for more resources devoted to the identification and treatment of FND.Perhaps most notable was the significant degree of functional impairment in this population, with over a third of patients not working due to FND and 26% receiving disability benefits, underscoring the social impacts of this condition.Also striking was the fact that across all three sites, a mean symptom duration of 6 years preceded FND specialist referral, illustrative of the fact that despite increasing focus on FND in neurology and psychiatric care, significant barriers remain to diagnosis, education, and treatment in this population.Finally, variations in the nature and degree of involvement of, or referral to, psychiatric/psychological professionals were noted across the three sites; perhaps of most interest is that a significantly higher percentage of patients at the Bern University Hospital clinic accepted referral to psychotherapy resources.This clinic is primarily staffed by neurologists dually trained in psychosomatic medicine, utilizes a CBT-based approach to address symptom management, and includes psychologists embedded within the clinic.

Strengths & Weaknesses:
As a retrospective study examining three tertiary care clinics, the study may not be generalizable to all FND patients and may be biased toward patients who do accept such referrals and/or are treated in medical centers that have them.As a review of data collected within such clinics, the strengths are primarily the reflections on the successes and challenges within this specialized patient population and offers evidence to guide treatment as well as develop specialist case at other sites.

Relevance to Consultation-Liaison Psychiatrists:
Patients with FND are perhaps one of the most “classic” patients with CL psychiatry, and from the consultant’s perspective, almost in no other population are the dual needs of providing both diagnosis and treatment for the patient, as well as education and liaison with the consulting medical team, both so critical.As FND straddle the fields of neurology and psychiatry, it has long been clear that successful treatment must be a collaborative and multidisciplinary effort.While the findings of this report may be unsurprising to those with experience in this population, they further underscore the need for earlier diagnosis and management, as well as offering insights into the development of multidisciplinary systems to advance this clinical field.

Type of study:
Cohort study

Findings:
This article, also published in the winter special edition on FND in Journal of Neuropsychiatry and Clinical Neurosciences, yields both descriptive data on specific symptoms within the mFND patient population (primarily weakness, pain, and tremor). More importantly, the only predictor of positive response to CBT was found to be patient acceptance of a psychological explanation of symptoms prior to beginning treatment, although the authors note that three patients within the study who did not accept this premise prior to commencing CBT also did show improvement, suggesting that perhaps this should not necessarily exclude patients from CBT referral.  Finally, CBT was shown to lead to symptomatic improvement in 49% of mFND patients, which did not significantly differ from results in the control population, and in fact may be superior to previous literature on outcomes in mFND.

Strengths & Weaknesses:
The study benefits primarily from being the first study specifically focusing on CBT for mFND, as well as the selection of a non-FND neuropsychiatric population, also treated with CBT, for the control group.  Weaknesses include a fairly small sample size and lack of a randomized, prospective design to mitigate selection bias, placebo effect, and to ensure standardized goals and structures within the CBT program.

Relevance to Consultation-Liaison Psychiatrists:
mFND is increasingly recognized as a unique subpopulation within functional neurologic disorders with specialized treatment needs.  While further data are needed to guide tailored care for this group, this study offers some evidence that CBT is both feasible and effective in improving mFND symptoms.  That the nuance of delivering a diagnosis of FND is critical for patient acceptance has long been an established element; as CL psychiatrists working within tertiary care centers are often the first to make the diagnosis of FND, framing the diagnosis using CBT principles may be an effective component of patient acceptance of the diagnosis and openness to further care. 

Type of study:
Case-control